Failure to Provide Incontinence Care and ADL Assistance
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, muscle weakness, above-the-knee amputation, aphasia, and deafness did not receive appropriate assistance with activities of daily living (ADLs), specifically incontinence care. The resident was documented as always incontinent and required a check and change program, as indicated in the Bladder Incontinence Evaluation. However, the resident's care plan did not address incontinence or the need for a check and change program, and the Kardex lacked specific instructions regarding incontinence care. Direct observation revealed that the resident remained in a geriatric chair in the day room for several hours without any incontinence checks by staff. The resident was moved between locations by staff and participated in activities, but at no point during the observed period was incontinence care provided. The resident exhibited signs of discomfort, such as yelling out and squirming in the chair, but staff did not respond with incontinence checks or care until the resident was eventually taken to their room.